Monday, January 9, 2017

The Guidelineification of American Medicine

His voice was gruff and his expression surly.

I don't want any more medications.

His face was indented by deep clefts, remnants of eight decades of life hard lived. His tone was commanding and certain. I knew that he was fond of me, but I could feel his patience slipping. He neither asked about nor accepted his diagnosis of heart failure. I could tell him till I was blue (or he was for that matter) in the face that his low ejection fraction portended a poor prognosis, and national guidelines suggested both a beta blocker and defibrillator placement.

He wouldn't budge. And before the age of electronic medical records, evidence based medicine, and quality scores, no one really cared. Before we would have taken the patient's wishes into account. Noted that he couldn't afford the new med, nor was particularly compliant with his other medications. Considered that his wife had died a few years back, and he had no interest in extending his life. Weighed the positives and negatives from the patients perspective, and come to a tailored decision for this particular human being.

But now the guidelineification of American medicine has turned this proud and aged skill into a humdrum maze of algorithms.

Algorithms that are more expert opinion and less evidence based. Algorithms that rely on evidence collected from typical white male patients with isolated disease processes and may not be generalizable. Algorithms that will change often and probably contradict themselves in the decades to come.

The true art of medicine, expertly meshing the known with the unknown. Factoring in human variability and preference to develop a unique plan. Has been lost. Ridiculed. Chewed and spit into the trash.

We pray to the ever eroding alter of longevity. Even as our patients have abandoned such false deities.

They want quality of life. They want control over their own decisions. They want to go with their gut sometimes.